Cholelithiasis

Alternative names

Gallstones

Definition

Cholelithiasis is the presence of gallstones in the gallbladder without any associated symptoms.

Causes, incidence, and risk factors

Cholelithiasis is usually incidentally discovered by routine x-ray study, surgery, or autopsy. Virtually all gallstones are formed within the gallbladder, an organ that normally functions to store bile excreted from the liver.

Bile is a solution composed of water, bile salts, lecithin, cholesterol and some other small solutes. Changes in the relative concentration of these components may cause precipitation from solution and formation of a nidus, or nest, around which gallstones are formed.

These stones may be as small as a grain of sand, or they may become as large as an inch in diameter, depending on how much time has elapsed from their initial formation. Depending on the main substance that initiated their formation (for instance, cholesterol), they may be yellow or otherwise pigmented in color.

Cholelithiasis is a common health problem worldwide, affecting approximately 1 out of 1,000 people. The prevalence is greater in women, Native Americans, and people over the age of 40.

Symptoms

Symptoms usually manifest after a stone of sufficient size (larger than 8mm) blocks the cystic duct or the common bile duct. The cystic duct drains the gallbladder, and the common bile duct is the main duct draining into the duodenum.

Collectively, these ducts form part of the biliary system . A stone blocking the opening from the gallbladder or cystic duct usually produces symptoms of biliary colic, which is right upper quadrant abdominal pain that feels like cramping. If the stone does not pass into the duodenum, but continues to block the cystic duct, acute cholecystitis results.

If the common bile duct is blocked for a substantial period of time, certain bacteria may find their way up behind the stone and grow in the stagnant bile, producing symptoms of cholangitis . Cholangitis is a serious condition and usually requires hospitalization. Continued blockage of normal bile flow may produce jaundice .

Stones blocking the lower end of the common bile duct where it enters the duodenum may obstruct secretion from the pancreas, producing pancreatitis. This condition can also be serious and may require hospitalization. In general, pay attention to the following symptoms:

Abdominal pain in the right upper quadrant or in the middle of the upper abdomen, which:

May be recurrent

May be sharp, cramping, or dull

May radiate to the back or below the right shoulder blade

May be made worse by fatty or greasy foods

Occurs within minutes of a meal

Jaundice

Fever

Note: Often there are no symptoms.

Additional symptoms that may be associated with this disease:

Stools, clay-colored

Nausea and vomiting

Heartburn

Gas or excessive flatus

Abdominal indigestion

Abdominal fullness, gaseous

Signs and tests

There are numerous tests to detect the presence of gallstones or gallbladder inflammation:

Abdominal ultrasound

Abdominal CT scan

Abdominal x-ray

Oral cholecystogram

Gall bladder radionuclide scan

ERCP ( endoscopic retrograde cholangiopancreatography )

This disease may also alter the results of the following tests:

Fecal fat quantitation

Bilirubin; urine

Abdominal MRI

Treatment

Since the first recognized case of cholelithiasis over 1500 years ago, numerous treatments have been used. These are primarily medical and surgical.

Bile salts taken orally may dissolve gallstones in those with a functioning gallbladder, but the process may take 2 years or longer, and stones may recur after the therapy is discontinued.

Medical dissolution, using both high-dose and low-dose chenodeoxycholic acids (CDCA, chenediol) was an approach investigated in the early 1980s. However, it was successful in only 14% of cases, required a long period of administration and a lifetime of maintenance therapy.

Urodeoxycholic acid (UDCA, ursodiol), a more contemporary medical therapy, is successful in only 40% of cases. Both CDCA and UDCA therapies are useful only for gallstones formed from cholesterol.

Other chemical methods include contact dissolution in which a catheter is passed through the abdominal wall and into the gallbladder and methyl tert-butyl ether, a volatile chemical, is then instilled. This chemical rapidly dissolves cholesterol stones but potential toxicity, stone recurrence, and other complications limit its utility.

Electrohydraulic shock wave lithotripsy (ESWL) has also been employed to treat cholelithiasis. The principal of this method is electromagnetically produced high-energy shock waves focused on a specific point in a liquid medium, producing fragmentation.

This approach was particularly popular in the mid to late 1980s, when some studies found it to clear gallstones in up to 60% of patients. However, its application is limited if there are a large number of stones present, if the stones are very large, or in the presence of acute cholecystitis or cholangitis. It can also be used in association with UDCA to improve its effect.

Despite these medical approaches, modern advances in surgical management have revolutionized the treatment of cholelithiasis. In general, surgery is indicated for symptomatic disease only.

In the past, open cholecystectomy was the usual procedure for uncomplicated cases. This operation necessitated a medium to large abdominal surgical incision just below the right lower rib in order to gain access to the gallbladder. After this operation, a patient typically spent 3-5 days in the hospital recovering.

However, in the early to mid 1980s, a new minimally-invasive technique called laparoscopic cholecystectomy was introduced which used small incisions and camera guidance in order to remove the gallbladder containing the symptomatic stones.

Currently, laparoscopic cholecystectomy is the gold standard for care of symptomatic cholelithiasis and is one of the most common operations performed in hospitals today. Using this approach, a patient with symptomatic cholelithiasis may have their gallbladder removed in the morning and be discharged from the hospital on the same evening or the next morning.

In addition, gallstones blocking the common bile duct may be visualized and removed during the laparoscopic procedure. Because this surgical treatment method has a complication rate of less than 1%, it has supplanted medical approaches to the treatment of gallstones.

Expectations (prognosis)

Gallstones develop in many people without causing symptoms. The chance of symptoms or complications resulting from cholelithiasis is about 20%. With current surgical approaches, the outcome is excellent with no recurrence of symptoms in over 99% of individuals.

Complications

Acute cholecystitis

Cholangitis

Chronic cholecystitis

Choledocholithiasis

pancreatitis

Calling your health care provider

Call for an appointment with your health care provider if symptoms of right upper quadrant abdominal pain persist or recur, jaundice develops, or other symptoms suggestive of cholelithiasis occur.

Prevention

There is no known way to prevent gallstones. If you have gallstone symptoms, eating a low fat diet and losing weight may be helpful in controlling symptoms.

Update Date: 10/9/2003

Christian Stone, M. D., Division of Gastroenterology, Washington University in St. Louis School of Medicine, St. Louis, MO. Review provided by VeriMed Healthcare Network.